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The Geriatrician clinicians of the Texas Elder Abuse and Mistreatment Institute – Forensic Assessment Center Network (TEAM-FACN) in Houston, have many years of experience providing capacity assessment services for Adult Protective Services (APS) and Texas courts. A process has developed which is efficient, consistent, and evidence-informed. In the last two years, telecommunication has been added to this process to conduct assessments of APS clients in areas of Texas remote from the Houston area. Of the 545 capacity assessments TEAM-FACN has completed across the state of Texas over the first two years of adding telecommunication, 211 (39%) were conducted with in-person interviews and 334 (61%) were conducted using videoconference interviews. APS and the courts in remote areas of Texas have embraced the use of the videoconference assisted capacity assessments. This article describes this evidence-informed process and how telecommunication technology is incorporated to expand the reach of the service. [ABSTRACT FROM AUTHOR]

Objectives: To describe the Texas Elder Abuse and Mistreatment Institute Forensic Assessment Center Network (TEAM‐FACN), a novel statewide elder mistreatment (EM) virtual assessment program using low‐cost videophone technology and innovative web‐based coordination to connect an Adult Protective Services (APS) agency and its clients, rural and urban, to a centralized geriatric and EM expert medical team for virtual in‐home assessments. Design: Descriptive. Setting: Community. Participants: APS clients aged 18 and older. Intervention: Virtual and in‐home assessments. Measurements: Program use and type of services provided. Results: In the first 8 months, 300 APS clients from all regions of the state were referred for assessment. Outcomes realized include a quadrupling in number of client assessments. TEAM‐FACN physicians provided an average of 2 services, which included 216 mental health assessments, with 123 conducted virtually; 42 medical assessments; 45 guardianship filings; 5 employee misconduct registry reviews; and more than 230 interdisciplinary team meetings to discuss case findings, safety plans, and medical and social interventions. Conclusion: TEAM‐FACN provides an innovative and viable way to increase access of urban and rural older and adults who are being mistreated to expert geriatric and EM protective service assessments. J Am Geriatr Soc 67:151–155, 2019. [ABSTRACT FROM AUTHOR]

Objectives To determine whether there are subtypes of elder self-neglect ( SN) with different risk factors that can be targeted using medical and social interventions. Design Cohort study using archived data of Adult Protective Services ( APS) substantiated cases of elder SN between January 1, 2004, and December 31, 2008. Setting Houston, Harris County, Texas. Participants Adults aged 65 and older with APS region VI substantiated SN between January 1, 2004, and December 31, 2008 (N = 5,686). Measurements Adult Protective Services caseworkers used the Client Assessment and Risk Evaluation ( CARE) tool during home investigations, assessing risk of harm in the domains of living conditions, financial status, physical and medical status, mental health, and social connectedness. Latent class analysis was used to identify unique subtypes of elder SN. Results Four unique subtypes of elder SN were identified, with approximately 50% of individuals manifesting physical and medical neglect problems. Other subtypes included environmental neglect (22%), global neglect (21%), and financial neglect (9%). Older age, Caucasian descent, and mental status problems were more strongly associated with global neglect behaviors. African Americans were more likely to experience financial and environmental neglect than Caucasians and non-white Hispanics. Conclusion Elder SN consists of unique subtypes that may be amenable to customized multidisciplinary interventions. Future studies are needed to determine whether these subtypes impose differential mortality risks and whether multidisciplinary tailored interventions can reduce SN and prevent early mortality. [ABSTRACT FROM AUTHOR]

Despite the public health implications of self-neglect, no tool exists for characterizing this condition. Self-neglecters often have no caregivers or surrogates to interview regarding the neglect and are often too cognitively impaired to provide valid self-reports. In response to this need, researchers from the Consortium for Research in Elder Self-neglect of Texas (CREST) collaborated with other experts in the field of elder self-neglect to design the Self-neglect Severity Scale (SSS). The SSS assesses three domains of self-neglect (hygiene, functioning, and environment) and relies on observational ratings assigned by trained observers. After pilot testing and revision, the SSS was field tested in the homes of subjects who had been reported to and substantiated by Texas Adult Protective Services (APS) as self-neglecting and compared with results of subjects recruited from a local geriatric clinic who were reported to APS but had no history of self-neglect. The first field test demonstrated that the SSS could distinguish elderly self-neglecters from community dwellers who do not self-neglect. The SSS exhibited adequate scale reliability (Cronbach alpha) and correlation with case status. Interrater reliability also appeared adequate, although sensitivity and specificity fell below the conventional acceptable range. Future methods are proposed for refining the SSS to improve its use as the benchmark for identifying elder self-neglect. [ABSTRACT FROM AUTHOR]

The article focuses on the research conducted by Fernandez and colleague regarding the psychological, social effects and higher mortality rate experienced by older people during times of disaster in the U.S.. Results show that impaired physical mobility, diminished sensory awareness, preexisting health conditions and social and economic restraints increased the vulnerability of frail older people during calamities. It is suggested that authorities should have a pre-disaster and post-disaster planning to ensure the safety of vulnerable and frail elders. Factors to be considered include immediate medical care, physical and social needs and shelter settings.

Describes the experience of an interdisciplinary team with abused or neglected elders who underwent interdisciplinary geriatric assessment and intervention. Methodology; Results and discussion.

The article discusses a study which explored the frailty status of a sample of older adults with Adult Protective Services (APS)-substantiated self-neglect participating in a vitamin D intervention study. It notes that frail older adults have a 2-fold increase in risk of mortality and prefrail older adults have a 1-fold increase risk of mortality when compared to robust older adults. It suggests that strength training and balancing exercises can minimize age-related muscle loss.

A recent Institute of Medicine report on geriatric work force issues recommends training residents in settings with geriatric patients and increasing certification requirements to include competence in the care of older adults. Although the number of internal medicine programs with a geriatric curriculum has increased, the scope and effectiveness of these programs vary. The purpose of this study was to evaluate the effect of a new academic geriatric and palliative medicine curriculum on the knowledge and attitudes of third-year internal medicine and fourth-year medicine and pediatrics residents. The study was conducted at The University of Texas Medical School at Houston. A new Division of Geriatric and Palliative medicine was created that offered inpatient, consultation, ambulatory, and home visit experiences in addition to didactic lectures. The University of Michigan Geriatrics Clinical Decision Making Assessment and the University of California at Los Angeles Geriatric Attitude Test was used to evaluate pre- and post-rotation knowledge and attitudes. Residents' knowledge improved after completing the rotation, as shown by a 6.9-point increase in posttest scores ( P<.001). There was also a 10-point improvement in pretest scores over the course of the year ( P=.03). Fifty-seven percent of residents had an improvement in attitude. This study shows that an increase in geriatric and palliative teaching opportunities provided by the establishment of a geriatric and palliative medicine division improves residents' knowledge significantly. [ABSTRACT FROM AUTHOR]

The article describes the development of a cross-sector collaboration between health, social and academic research systems to meet the needs of vulnerable homebound older adults during the COVID-19 pandemic. Topics discussed include pre-pandemic example of successful collaboration, integrated health and community-based care, and adverse impact of the pandemic on the Meals on Wheels national nutritional and social services program.

Senior financial exploitation (FE) is prevalent and harmful. Its often insidious nature and co-occurrence with other forms of mistreatment make detection and substantiation challenging. A secondary data analysis of N = 8,800 Adult Protective Services substantiated senior mistreatment cases, using machine learning algorithms, was conducted to determine when pure FE versus hybrid FE was occurring. FE represented N = 2514 (29%) of the cases with 78% being pure FE. Victim suicidal ideation and threatening behaviors, injuries, drug paraphernalia, contentious relationships, caregiver stress, and burnout and victims needing assistance were most important for differentiating FE vs non-FE-related mistreatment. The inability to afford housing, medications, food, and medical care as well as victims suffering from intellectual disability disorder(s) predicted hybrid FE. This study distinguishes socioecological factors strongly associated with the presence of FE during protective service investigations. These findings support existing and new indicators of FE and could inform protective service investigation practices. [ABSTRACT FROM AUTHOR]

Background: Elder mistreatment is common and has serious social and medical consequences for victims. Though programs to combat this mistreatment have been developed and implemented for more than three decades, previous systematic literature reviews have found few successful ones. Objective: To conduct a more comprehensive examination of programs to improve elder mistreatment identification, intervention, or prevention, including those that had not undergone evaluation. Design: Systematic review. Setting: Ovid MEDLINE, Ovid EMBASE, Cochrane Library, PsycINFO Elton B. Stephens Co. (EBSCO), AgeLine, CINAHL. Measurements: We abstracted key information about each program and categorized programs into 14 types and 9 subtypes. For programs that reported an impact evaluation, we systematically assessed the study quality. We also systematically examined the potential for programs to be successfully implemented in environments with limited resources available. Results: We found 116 articles describing 115 elder mistreatment programs. Of these articles, 43% focused on improving prevention, 50% focused on identification, and 95% focused on intervention, with 66% having multiple foci. The most common types of program were: educational (53%), multidisciplinary team (MDT) (21%), psychoeducation/therapy/counseling (15%), and legal services/support (8%). Of the programs, 13% integrated an acute‐care hospital, 43% had high potential to work in low‐resource environments, and 57% reported an attempt to evaluate program impact, but only 2% used a high‐quality study design. Conclusion: Many programs to combat elder mistreatment have been developed and implemented, with the majority focusing on education and MDT development. Though more than half reported evaluation of program impact, few used high‐quality study design. Many have the potential to work in low‐resource environments. Acute‐care hospitals were infrequently integrated into programs. See related editorial by Kathleen Wilber in this issue. [ABSTRACT FROM AUTHOR]

Objectives: Interventions are critical to improving clinical outcomes in elder self-neglecters. This study assessed feasibility of a randomized controlled trial of oral vitamin D in Adult Protective Services-substantiated self-neglect clients ≥65 years. Methods: Participants were directly observed to consume ergocalciferol 50,000 IU (treatment) or ergocalciferol 400 IU (control), once a month, for 10 months. For months 6-10, half the control group randomly crossed into the treatment group (crossover). Intervention feasibility was measured by number of potential participants who agreed to participate and by retention rates during the study. Results: Ninety-four referrals were received and 59 (63%) agreed to participate. Forty-nine participants were enrolled after prescreening and 35 completed the two-phase trial for a 72% retention rate. The participants’ average age was 75.2 ± 6.8 years, mainly female (59%), African-American (47%), and living alone (41%). Discussion: Despite assumptions that self-neglecters are resistant to care, we have successfully conducted the first clinical intervention in this vulnerable population. [ABSTRACT FROM AUTHOR]

Looks at law and legislation to prevent elder abuse in the U.S. Estimated incidence of elder abuse in the U.S. each year; Goal of the National Center for Injury Prevention and Control and the Centers for Disease Control and Prevention (CDC) to address the problem of elder abuse in the U.S.; Critique of the enforcement of Adult Protective Services (APS) law in U.S. states; Impact of a task force in Delaware on the detection and prevention of elder abuse; Description of the Texas Elder Abuse and Mistreatment Institute (TEAM), which offers intervention in cases of elder abuse in cooperation with other human service agencies.

Background Medication non-adherence can exacerbate disease severity, leading to impairments that interfere with self-care activities in older adults, and, ultimately, death. Elder self-neglect is the most common report to Adult Protective Services (APS) across the USA and is a significant risk factor for early mortality. These individuals often suffer from multiple comorbid diseases that require careful management, but for various reasons they are unwilling or unable to provide themselves with the self-care resources necessary for maintaining health and safety. No studies have assessed whether medication adherence is associated with elder self-neglect. Objective The purpose of this study was to assess and describe medication adherence in this population, as well as evaluate associations between medication adherence and cognitive impairment, depression, physical function, and abilities to perform basic and instrumental activities of deily living (BADL5 and IADLs). Methods A cross-sectional study of 100 communitydwelling adults 65 years of age and older with APS-subs:antiated elder self-neglect were assessed. In-home cornprehensive geriatric assessments (CGAs) were completed and included medication reviews. Information on each medication, including the amount taken from the date dispensed, was collected and used to determine adherence. The criteria for non-adherence were taking <80 or >110 % of at least one medication. The sample was also split into groups of low adherence (≤29 %), moderate adherence (29-86 %) and high adherence (≥86 %). Scores on the CGA measures Mini-Mental State Examination, Geriatric Depression Scale, Physical Performance Test (PPT) and Kohlman Evaluation of Living Skills were assessed to determine whether cognitive impairment, depression, physical function, and/or ability to perform BADLs and IADLs were associated with non-adherence or low, moderate or high levels of adherence. Results Twenty-five per cent of the sample was taking more than seven medications daily. The average rate of adherence was 59 %. Only eight participants (10 %) were adherent to their entire medication regimen, and thus, 90 % were considered non-adherent to at least one medication. The mean number of medications to which individuals were non-adherent was 3.4. The cognitive impairment, depression, physical function and BADL/IADL measures were not statistically associated with medication nonadherence using the cut-points of <80 or >110 %. However, when split into tertiles, the lowest medication adherence level (≤29 %) was significantly associated with a greater number of medications being consumed and lower objective physical function levels as measured by the PPT. Conclusions Medication non-adherence is a very prevalent problem among older adults who are self-neglecting, and higher non-adherence levels were associated with the number of medications being consumed as well as lower physical function. Physicians who find high rates of medication non-adherence in their patients should consider barriers to adherence, including a large number of medications, lower physical function and the possibility of elder self-neglect. Future efforts should focus on studying the underlying reasons for medication non-adherence in larger samples of older adults who are self-neglecting. This would facilitate the development of interventions to reduce medication non-adherence in this population. [ABSTRACT FROM AUTHOR]

Acute Care for the Elderly (ACE) units have successfully decreased length of stay, hospital costs, and readmission rates. Furthermore, patients return home with increased functional capacity and improved satisfaction with their hospital stay. The ACE unit concept was geared toward patients returning to independent living, but the average hospitalized geriatric patient is increasingly more frail, vulnerable, and dependent. The purpose of this study is 2-fold: (1) to determine if the ACE unit continues to offer the same benefit to the frail, often bedbound elderly, and (2) to determine if such a unit is able to maintain standard hospital quality indicators. A total of 1096 cases discharged from the Memorial-Hermann ACE unit between July 2008 and June 2010 were compared to a sample of 383 patients with similar illness severity who were discharged between July 2007 and June 2008. Metrics measured include: average length of stay (ALOS), case mix index (CMI), case mix adjusted average length of stay (CMI adj ALOS), average direct costs per case, and readmission rate. Patient satisfaction was measured using Hospital Consumer Assessment of Healthcare Providers and Systems and Press-Ganey surveys; quality and safety data were provided by Memorial-Hermann's Quality and Safety Department. The ACE unit resulted in a statistically significant decrease in ALOS and CMI adj LOS with a simultaneous increase in Health Care Financing Administration CMI, indicating that the unit was serving a sicker, more frail population. The readmission rate was 11.95%. The decrease in length of stay, readmission rate, and direct cost translates into a decrease in cost per case. Furthermore, the ACE unit successfully met hospital quality indicators. ( Population Health Management 2012;15:236-240) [ABSTRACT FROM AUTHOR]

Identifying impairments in the capacity to make and execute decisions is critical to the assessment and remediation of elder self-neglect. Few capacity assessment tools are available for use outside of healthcare settings, and none have been validated in the context of elder self-neglect. Health and social services professionals are in need of validated tools to assess capacity for self-care and self-protection (SC&P) during initial evaluations of older adults with suspected self-neglect syndrome. Currently, legal and medical declarations of incapacity and guardianship rely on clinical evaluations and instruments developed to assess only decision-making capacity. This article first describes the conceptual and methodological challenges to assessing the capacity to make and execute decisions regarding safe and independent living. Second, the article describes the pragmatic obstacles to developing a screening tool for the capacity for SC&P. Finally, the article outlines the process for validation and field testing of the screening tool. Social services professionals can then use a valid and feasible screening tool during field assessments to screen for potential impairments in the capacity for SC&P in vulnerable older adults. [ABSTRACT FROM AUTHOR]

Purpose: We sought to characterize self-neglect definitively as a geriatric syndrome by identifying an association with functional impairment. Design and Methods: We performed a cross-sectional home evaluation of 1 00 community-living older adults referred by Adult Protective Services for geriatric self-neglect and 100 matched adults from a community geriatrics clinic. We made our assessments by using two manual muscle tests, a timed-gait test, a modified Physical Performance Test (mPPT), and the Kohlman Evaluation of Living Skills (KELS). Results: Participants in the self-neglect group had impaired mPPT (p < .077) and KELS (p < .001) scores compared with community-controls. Using analysis of covariance models, we found that self-neglect referral explained a significant proportion of the variance in KELS scores (32%; p < .001) but not in mPPT scores (22%; p = .49). Implications: The geriatric syndrome of self-neglect is associated with increased morbidity and mortality and appears to be independently associated with impairments in instrumental activities of daily living. The evaluation and treatment of geriatric self-neglect should be consistent with that of other geriatric syndromes. [ABSTRACT FROM AUTHOR]

Self-neglect is a serious and burgeoning public health challenge representing the most common problem faced by Adult Protective Services agencies. Among older adults who are vulnerable to self-neglect, the capacity to make decisions may remain intact. However, the capacity to identify and extract oneself from harmful situations, circumstances, or relationships may be diminished. A key ethical and clinical branch point in identifying older adults at risk for self-neglect involves determining whether the individual can both make and implement decisions regarding personal needs, health, and safety. The Articulate →Demonstrate method is a practical and efficient way to screen capacity in the setting of suspected self-neglect. Once self-neglect has been identified, common clinical interventions can be targeted to the diagnosed deficits that foster vulnerability to neglect in older adults. [ABSTRACT FROM AUTHOR]

Elder self-neglect is the most common form of elder mistreatment. Individuals who cannot provide basic needs for themselves may develop social, functional, and physical deficits. The systematic characterization of self-neglecting individuals is the goal of the Consortium for Research in Elder Self-Neglect of Texas project. This study reports on the nutritional status of self-neglecting elderly. Self-neglectors (SN) were recruited based on referrals along with matched control (CN) subjects. Data are for 40 SN subjects (age 76 +/- 7 y) and 40 CN subjects (76 +/- 7 y). Blood samples were collected and analyzed for indices of nutritional status. SN subjects had a greater serum concentration of total homocysteine than CN subjects (13.6 +/- 4.5 vs. 11.6 +/- 5.6 micromol/L, P < 0.05) and a lower concentration of red blood cell folate (1380 +/- 514 vs. 1792 +/- 793 nmol/L, P < 0.05). Plasma beta-carotene and alpha-tocopherol were lower in SN subjects (0.28 +/- 0.2 vs. 0.43 +/- 0.33 micromol/L; 23.2 +/- 9.3 vs. 27.8 +/- 9.3 micromol/L, P < 0.05). SN subjects had a lower serum concentration of 25-hydroxyvitamin D than CN subjects (33.7 +/- 16.4 vs. 44.1 +/- 19.6 nmol/L, P < 0.05). These differences in markers of nutritional status show that the self-neglecting elderly are at risk for altered nutritional status, particularly of folate, antioxidants, and vitamin D. Evaluation of these data in relation to other functional and cognitive assessments are critical for evaluating the relation between nutrition and self-neglect. [ABSTRACT FROM AUTHOR]